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Panic disorder and Phobias (Typical Symptoms and Associated Clinical…
Panic disorder and Phobias
Four types
Panic disorder
: typified by recurrent attacks that involve the rapid onset of multiple physical symptoms, as well as fear of future attacks
Agoraphobia
: characterised by avoidance of situations where anxiety or panic symptoms might occur, especially when escape may be difficult
Social phobia
('social anxiety disorder'): involves intense anxiety or avoidance of interpersonal and/or performance situations fuelled by fear of negative evaluation by others
Specific phobia
: characterised by excessive fear toward a particular object or situation, certain natural environments and closed spaces
Typical Symptoms and Associated Clinical Features
Common features suggest that a dimensional perspective: subjective distress is present on a continuum from diffuse worry and future-oriented anxious apprehension, to more specific targeted fears, to imminent threat and panic
Anxious individuals strive to make their world feel 'safe': overly on cues or signals in environment that help to reduce their distress at entering feared situations
Process information in distorted ways: cognitive processes biases, preferential processing of cues tied to threat or danger
Physiological responding: fight-or-flight reaction, autonomic arousal that motivate the individual either to escape or avoid situations or defend oneself
Emotional response systems: common signs and consequences of anxious arousal, pointing to phenomenological presentation
Panic Disorder and Agoraphobia
Defined by recurrent and unexpected panic attacks, followed by at least 1 month fear about future panic attacks, concern about consequences of attacks, or changes in behaviour related to attacks
Attack must involve a distinct period of intense discomform and/or fear that rises to a peak within minutes - many physical symptoms, attacks that involve fewer than four = limited symptom attacks
The attacks themselves become a problem, as indicated by fear of future attacks and altered behaviour in response to attacks
Lifetime prevalence of nonclinical panic attacks: 10-15% in general population
Panic attacks unexpected: uncured attacks occur in situations where the person is unaware of the precipitating factors: triggers, situational events, emotional circumstance - start to avoid situations or feelings
Agoraphobia
Intense anxiety about at least two situations or places which escape might be difficult or help unavailable should a panic attack or symptoms occur: least 6 months, feared situations avoided
Common situations: various mode of transportation, avoidance of internal sensations
Significant impairment: social activities, marital functioning, sleep dysregulation, increased risk for suicide attempts
Social Phobia/Social Anxiety Disorder
Marked and persistent fears of social interactions or performance situations in which scrutiny by others is possible: at least 6 months, significant anticipatory anxiety is common
More critical of their social performances; unable to make desired impressions upon others; extreme fears of negative evaluation
Shyness: social phobia more extreme
Alcohol problems are quite high, they drink to help them minimise anxiety
Specific Phobia
Defined by disproportionate and persistent fear toward a particular object or situation that typically lasts at least 6 months to qualify for a diagnosis: differential diagnosis a challenge
Always evoke an extreme and immediate fear reaction; phobic target must be avoided or endured with severe distress
Phobia can be directed toward any target: subtype delineation were based in part on differences across the phobias in typical ages of inset, comorbidity patterns, physiological responses and gender prevalence
Strong physiological response: panic attack is common reaction for persons with specific phobias upon encountering their feared object/situation - blood-injection-injury phobia: sudden decrease in heart rate and blood pressure, lead to fainting
Pattern of biased information processing that favours fear-relevant stimuli: general pattern of findings indicates individuals with specific phobias selectively attend to fear-relevant information, and interpret ambiguous information in a threatening manner
Memory bias: linking phobic target with fear at a level outside conscious control - disgust promotes avoidance (disease avoidance model), oversensitive 'false alarm' system
Clinical implications
One or more responses system: behavioural, physiological, expressive emotion, and/or cognitive - different response systems not closely aligned and may not change in tandem = desynchronise/uncoupling
Avoidance of therapy itself: strong therapeutic alliance
Physiological reactions: increased activation of sympathetic nervous system - involuntary, not being in control; encourage to tolerate, relaxation
Dysregulation of multiple emotions: fear/panic/anxiety, disgust; SP = shame and embarrassment (gener expectations), Panic = anger (lack of self-assertiveness)
Not feeling in control: work is unpredictable and uncontrollable = frame intervention as means by which patients can learn to manage their anxiety, reduce belief that patient is out of control, normalize experience of anxiety
Selective processing of threatening information: cognitive restructuring, however, simple refocus of attention and shift of disorder-relevant automatic associations or negative interpretations
Limitations of the DSM
Identification of symptoms alone is insufficient: ideographic targets of intervention needed
Challenges in differential diagnosis
Social anxiety category is heterogeneous
Impairment of functioning, love and work: disruption of relationships, consequent dependence on loved ones, not always easy for family members to change long-standing patterns of who is strong or helper members - decrease risk for relapse
Course
Panic disorder/agoraphobia
Presence of life stressors predictor of initial onset and intensity: stressors tied to interpersonal difficulties or physical well-being (scary experiences with drugs)
Cause show fluctuations: however chronic and disabling - remission rate only 39%, rate of recurrence higher for women (82) than men (51)
Relapse not unusual
CBT (10-15 weekly sessions): highest mean effect size - combination of psychoeducation, exposure (reducing avoidance + reentering feared situations), cognitive restructuring, relapse prevention = helpful for patients not responding to medication (more costeffective)
Medication: SSRI + SNRI (recommended), TCA (side effects), benzodiazepines (addiction): medication alone, CBT alone, combination of medical equally effective - following medication discontinuation, combination had worse outcomes
Panic-focused, psychodynamic, twice-weekly, 12-week psychotherapy may be helpful: confront emotional significant, reason for avoidance difficulty sepati
Outcomes vary for persons with substantial comorbidity, and many people not receiving treatment or are receiving substandard care
Social phobia
Fairly chronic with low rates of recovery and high rates of recurrence when left untreated: persists between 19-30 years, recovery rates from 27 to 52%, only 37% change of recovery, 39% change of recurrence
Interventions
CBT + CBGT (group): combining cognitive and exposure, individually tailored fear hierarchies - intervention effective, 22 to 95%
Pharmalogical interventions
Mean across CBT and pharmalogical treatments significantly different from zero, however they did not differ from one another
Phenelzine (monoamine oxidase inhibitor (MAOI) = largest symptoms improvements - problematic side effects
Paroxetine and sertraline (SSRIs) and venlafaxin: currently used
Patients should stabilise medication regimens prior to starting therapy and refrain from adjusting or changing medication during
Pharacotherapies may be more effective than CBT in short-term, and effects of medication on social anxiety occur rapidly: CBT may help patients maintain treatment gains long-term
Cognitive processing biases are not significantly correlated with symptoms of social anxiety but they may also be causally related
Specific phobias
Disorder quite stable and enduring without treatment: children grow out of fears
High succes-rate for exposure treatments: many choose to avoid feared object
Exposure: opportunity to learn that they can tolerate the fear: more favorable outcomes for in vivo exposure
Unfornuate that more people do not seek treatment: single session of exposure therapy is effective to treat spider phobia - general, multi-session treatments
Applied muscle tension to in vivo exposure for treatment of blood-injection-injury phobia: address decreases in blood pressure
In vivo: high dropout, discomfort
Cognitive therapies presented either alone or as an augmentation to exposure therapies, have received some support, though there is considerable heterogeneity in findings - CBT might be helpful for claustrophobia
Eye movement desensitization and reprocessing (EMDR): adds movement to an exposure-based therapy, elaboration of imaginal exposure
Pharmacological treatments: no widely investigated, D-cycloserine (agonist of NMDA receptor site) enhance pace of exposure therapy by stimulating amygdala and influencing how readily fear responses are unlearned
Clinical implications
Importance of the therapeutic alliance and experience
Challenge to get them to try it in the first place and to recognise that tolerating anxiety and exposing themselves to the feared situation do not impose any realistic danger; therapeutic alliance most important, strong bond needed
Framing therapy as means of teaching coping skills, were patients learn to manage and tolerate anxiety, is important
More experienced more succesful: not clear whether difference was function of alliance or the use of more general clinical skills
Making exposure therapy more appealing
Relaxation: can help patients to reduce anxiety and obtain sense of control - noting that relaxation can help to reduce one's resting level of anxiety, making panic and intense anxiety reactions less likely
Patient who are likely to fear losing control should be forewarned that sensations they may experience are not signs that they are losing control, but that they are learning to manage sensation of anxiety
Being familiar with principles of change
Therapists can enhance clinical effectiveness by being familiar with general therapeutic principles of change
Implementing techniques: fostering cognitive change, increasing behavioural skills for coping, reducing avoidance, repeatedly using emotionally evocative procedures
Epidemiology
Panic Disorder and Agoraphobia
Lifetime prevalence (with and without agoraphobia): 1,5-3,5% - presence of agoraphobia without panic is less common with 1,3% lifetime prevalence
Mean age of onset is 24 years of age: peak ages of onset at 15-24 years and then at 45-54 years: less common in prepubescent children - puberty is an important indicator of panic attacks, and many adolescents do experience experience panic attacks
Less pervasive for elderly populations: debate about validity of using DSM with older adults, high rates of medical comorbidity
Gender roles indicate it is more acceptable for women to avoid (and for men to terrain to substance abuse) may also be contributing factors: women are more likely to have severe agoraphobia
Social Phobia
Approximately 7-13% of individuals in Western societies have social phobia at some point in their lifetime: lifetime prevalence rate of 12,1% making it one of the most common disorders, may become more significant health concern in future
Median age of onset is 13 years: typically develops at a fairly young age, usually prior to age 18 - incidence lower in older than in younger
More prevalent in women than in men: equally distributed among treatment-seeking populations, not many gender differences in severity of symptoms
Threshold for receiving a diagnosis of social phobia differs across cultures, even though symptom profiles are the same
Specific Phobia
Lifetime prevalence: 11% = subclinical fears are also extremely common with the majority of the population reporting a significant fear: most frequent phobia focus on animals or heights
Mean age of onset: 15-16 years old - prevalence seems to peak between 25 and 54 years of age, while lower rates are observed among both younger /ages 18-25( and older (age 55+)
More prevalent among women, especially for fears of animals, ligtning, enclosed places and darkness; gender differences for phobias of heights, dentist, flying tend to be lower - mend tend to underreport their fear relative to women
Mend tend to underreport their fear relative to women; more women are apt to seek treatment for specific phobias, so gender gap is more pronounced in treatment-seeking samples
Clinical implications
Cultural and diversity issues in assessment and treatment
Essential to consider sociocultural context of patients: likely play a role in symptom presentation, assessment and treatment planning = diagnostic bias and inappropriate treatment
Age important: some older adults choose to describe symptoms of anxiety as problems with sleep, because less stigmatising; older adults reactive to anxiety-provoking triggers
Etiology
Levels of vulnerabilities and causal factors may interact to lead to the expression of a specific problem: Barlow, (1) general biological vulnerability, (2) general psychological vulnerability, (3) specific psychological vulnerabilities
General biological vulnerabilities
Broad genetic basis to anxiety and related areas of emotion dysregulation: first-degree relatives have higher rates of anxiety difficulties; children of parents with anxiety disorders have more than nine times greater risk; children of parents with panic disorder more anxious
Genetic factors appear to play moderate but meaningful role in development of social phobia, explaining 30-50% of variance in the disorder
Higher concordance rates of anxiety disorders in MZ (34%) than in DZ (17%)
Temperamental vulnerabilities tied to anxiety seem to play a role: behavioural inhibition, biomarkers (imbalance of serotonin (SSRI), differences in anatomy of amygdala and hippocampus, altered stress-response with respect to cortisol levels and HPA axis
Biological triggers: false-suffocation alarm theory - individuals who are sensitive to increased levels of CO2 may be a greater risk of developing panic attacks; baseline subjective distress, loss of control
General psychological vulnerabilities
See the world as uncontrollable and unpredictable: having minimal control over the environment during early development ca n lead to chronic difficulties with anxiety - attributional style reflecting a sense that outcomes are uncontrollable is risk factor
Gender disparity may be due to higher rates of negative life events during childhood and adolescence among girls, and more experiences that suggest one's behaviour has limited impact on the environment
Parenting styles promoting a sense of control of being contingently responsive yet not overprotective seem to protect
Stressful life-events seem to enhance vulnerability: higher number of salient life events, anxious individuals selectively process threatening information, interpret ambiguous situations as threatening (misinterpretations of bodily sensations)
Panic attacks occur because certain bodily sensations are misinterpreted as indicating a catastrophe
Information-processing biases enhance vulnerability to react more negatively to subsequent challenging life events: anxiety sensitivity
Specific psychological vulnerabilities
Combination of general biological and psychological vulnerabilities is thought to enhance anxiety proneness, while an individual's particular learning experiences are expected to predict whether or not a specific type of anxiety disorder is expressed
Mowrer's (1947) influential two-factor theory: fear becomes classically conditioned through negative conditioning event, then avoidance and escape behaviours are operantly reinforced because of anxiety-reducing qualities
Rachman suggested multiple pathways to acquire specific gears: a person may vicariously learn via modeling or simply through the transmission of information that a given situation is dangerous
Biological preparedness theory: predisposed to acquire some fears very readily because it was adaptive to be fearful of certain objects or situations in evolutionary past
Social skills and behaviours: poor social skills and interrupted social performance which they define as the interference of appropriate social behaviour due to heightened anxiety
Interrupted social performance plays a larger role in the maintenance of social anxiety: interrupted social performance interfere with one's ability to obtain and nurture friendships
Clinical implications
Connecting ethology to treatment: CBT emphasise here and now, a focus on ethology can have important therapeutic benefits, especially in discussing oncoming contributions to current fears from early life experiences
While anxiety may be partially a function of a biological vulnerability, a psychoeducational intervention could potentially allow them to reattribute one of the 'causes of their problems to something other than themselves
Etiological factors underlying panic can be highly idiosyncratic
Principles of change: (1) positive expectation that therapy will help and presence of sufficient motivation to participate, (2) optimal therapeutic alliance, (3) patients to become better aware of what they are doing/not doing, contribute to life problems and symptoms, (4) corrective experiences, (5) revaluation of biased thinking
Comorbidity
Panic Disorder and Agoraphobia
60% had a additional psychiatric disorder: approximately 20-50%of persons diagnosed with panic disorder also meet criteria for agoraphobia
Anxiety disorders: comorbidity with GAD, social and specific phobias; mood disorders (unipolar + bipolar) co-occur; lifetime prevalence of major depression is 35-40% (worse course for panic, including increased impairment and hospitalisations
Substance use complicates presentation of panic disorder: 20% meet criteria for alcohol or substance abuse - especially challenging to treat because of days that substance abuse interferes with treatment participation
Rates for comorbid PDs are also extremely high, with estimates of 40-50% of persons with panic disorder meet criteria for one PDs, typically avoidant, obsessive-compulsive or dependent; personality difficulties interact with aims of exposure-based therapy
Medical comorbidity: tendency of people with disorder believe that they are experiencing serious medical illness - higher prevalence of hypertension, angina, and other cardiac problems: ulcer disease, thyroid disease
Social phobia
Avoidant personality disorder ranging from 25-89%; high rate of comorbidity between social phobia and both depression and alcohol abuse and/or dependence, 41,4% of individuals who met criteria had coexisting affective disorder; 11% met criteria for alcohol abuse; 24% for alcohol dependence
81% of individuals qualified for another disorder: typically report that social phobia occurred first
Specific Phobia
Specific phobias occur with other specific phobias, only 24,4% diagnosed with specific phobia had a single phobia, many had more than three
Likely to have another anxiety disorders, but the specific phobia in these cases is usually less severe than the others disorders: when specific phobia is the most severe and impairing disorder, it is likely to be associated with other disorders
Clinical implications
Responding to oc-occcuring symptoms of physical illness
Somewhat higher prevalence of cardiac problems: help patients distinguish between signs of a heart attach and those of a panic attack - adjust exposure exercises so that patients can still meet goal of eliciting fear and panic while being careful of medically relevant limitations
Alternate ways to view comorbidity
Understanding of multiple problems is viewed in terms of 'comorbidity' rather than the potential functional relationship between problematic emotions, behaviours, cognitions
By focusing on principles of change, rather on diagnoses, it becomes easier to tackle multiple problems simultaneously
Treatment of anxiety disorder is less succesful if there is a comorbid PD: considering common vulnerabilities factors that can account for multiple problem manifestations can be helpful: underlying personality style + stressful life circumstances